The Reverse Cross Finger Flap.

The reverse cross finger flap is usually performed on patients with deep dorsal digital skin, nailbed, and extensor tendon injuries that cannot be repaired and grafted. These patients will require additional dorsal digital flaps from the adjacent fingers.

A hand surgeon's further experience with thoracic outlet compression syndrome.

Because hand surgeons frequently see patients with arm and hand pain, numbness, and tingling, it is important for them to recognize the possibility of the presence of thoracic outlet compression syndrome (TOCS). Approximately 40% to 50% of patients with this condition have associated peripheral nerve compression symptoms. Only about 10% of patients with suspected TOCS might show some objective evidence during physical examination and other examination modalities. For this reason, TOCS is one of the most overlooked, misdiagnosed, and underrated conditions. During the past 20 years (1989-2009) our surgical experience with combined-approach surgery for TOCS, involving transaxillary first rib resection followed by immediate transcervical anterior and middle scalenectomy, has been gratifying. During this period, more than 750 patients had this combined procedure. Between the end of 1989 and 2002 (13 years), 532 patients (many of whom were from out of state) had this kind of intervention. At the end of 2002, we surveyed our patients for the outcome of their surgery. Unfortunately, we were able to locate only 358 patients, and only 102 patients returned a mailed questionnaire. About 95 patients reported improvement of their symptoms. Since the beginning of 2003, more than 230 patients have had the same procedure. It is our impression that the outcome of the surgery in this last group of patients is at least as good as (if not better than) the earlier reported outcome in the first group of patients. The combined surgical approach to TOCS with transaxillary first rib resection and transcervical scalenectomy is the most complete procedure for total decompression of the thoracic outlet, with a much better rate of improvement of symptoms and a lower rate of recurrences. The surgical techniques of these two procedures are described.

History of thoracic outlet syndrome.

Thoracic outlet syndrome (TOS), a condition in which neurovascular structures in the thoracic outlet region are compressed, can be caused by anatomical abnormalities or acquired changes in the soft tissues and bony structures in the region. The brachial plexus is the most frequently affected structure. TOS is one of the most difficult neurovascular compressions in the upper extremity to manage because of the variability of complaints and the high risk associated with surgical treatment.

Thoracic outlet syndrome: anatomy.

The thoracic outlet region contains three important structures: the brachial plexus, the subclavian artery, and the subclavian vein. As they travel from the upper mediastinum to the upper extremity, these structures run through three important spaces: the interscalene triangle, the costoclavicular space, and the subpectoral space. Compression can occur in any of these three spaces because of structural anomalies or trauma.

Combined surgical treatment of thoracic outlet syndrome: transaxillary first rib resection and transcervical scalenectomy.

Transaxillary first rib resection and transcervical scalenectomy are common procedures used for treatment of thoracic outlet syndrome (TOS). In the early 1980s, some surgeons started to perform both procedures, starting with the scalenectomy and following with a transaxillary first rib resection. The author has found that performing these procedures in the reverse order, starting with the first rib resection and following immediately with a transcervical scalenectomy is an easier approach, providing total decompression, better relief of symptoms, and a lower recurrence rate.

Recurrent thoracic outlet syndrome.

In the author's experience, the rate of recurrence is lower (5%-10%) when a combined procedure (transaxillary first rib resection followed by immediate transcervical anterior and middle scalenectomy) is performed as the primary operation. The author strongly believes this combined procedure accomplishes an excellent decompression of the thoracic outlet area and decreases the rate of recurrence and reoperation. In addition, spontaneous recurrence most likely is caused when scar tissue gradually builds up in the surgical area. For this reason, as mentioned previously, the author instructs and encourages patients to start postoperative exercises the day after surgery and to continue these exercises for at least 6 months and preferably 1 year to improve brachial plexus and subclavian vessel gliding and to minimize the harmful effects of scar tissue.